dialysis access procedures · c) basilic vein transposition d) forearm loop arteriovenous graft e)...

2Dialysis Access ProceduresKhalid O. Khwaja

HemodialysisIntroductionSurgical Proceduresa) Radiocephalic Fistulab) Brachiocephalic Fistulac) Basilic Vein Transpositiond) Forearm Loop Arteriovenous Grafte) Upper Arm Arteriovenous Graftf) Lower Extremity Access Procedure

Peritoneal DialysisPeritoneal Dialysis Catheter Placementa) Open Techniqueb) Laparoscopic Technique

Hemodialysis

Introduction

Hemodialysis is one of the main modalities for renal replacement therapy in patientswith end-stage renal disease. Successful hemodialysis is contingent upon the creation ofproper vascular access. Chronic vascular access was first established in 1960 by Scribnerand colleagues when they created a shunt between the radial artery and the cephalic veinusing an external Silastic device. However, this device was fraught with problems suchas bleeding, clotting, and infection. In 1966, Breschia and Cimino described a surgicalfistula between the radial artery and the cephalic vein just proximal to the wrist, therebyeliminating the external shunt and enabling a high flow system for hemodialysis. To thisday, it remains the procedure of choice for patients with end-stage renal disease in needof chronic hemodialysis.

Several principles should be followed when planning vascular access surgery. Ingeneral, primary fistulas are better than prosthetic grafts due to better long-term patencyand lower risk of infection and thrombosis. The upper extremity is preferable to thelower extremity and the nondominant arm should be employed first. If possible, a distalsite should be selected first, preserving the upper arm for subsequent use. Careful pre-operative vascular assessment is performed with palpation of the radial, ulnar, andbrachial pulses; an Allen’s test is performed on both sides. The superficial veins of thearm should be carefully assessed with application of a proximal tourniquet. In somecases, the cephalic vein is readily evident at the wrist, antecubital fossa area, or in thelateral aspect of the upper arm. Once a decision has been made to perform access

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36 Atlas of Organ Transplantation

surgery, no venipunctures or blood pressure monitoring should be performed in thatarm. If no superficial veins are apparent, the venous system may be assessed by ultra-sound examination of the arm. Both the cephalic and basilic systems are interrogated,as well as the deep venous system and the central veins. Patients with suspected centralvenous stenosis or prior catheters inserted on the ipsilateral side, or with abnormalfindings on ultrasound, may be assessed by conventional venography. If central stenosesare found, they should be corrected by endovascular techniques preoperatively, or analternate site for access should be sought.

Vascular access should be established prior to the actual need for hemodialysis,thereby avoiding temporary external catheters, which have a higher risk of infection andare also associated with central venous stenosis. This chapter discusses the technique forsome common permanent access procedures.

Surgical Procedures

a) Radiocephalic Fistula

The radiocephalic fistula, as described by Breschia and Cimino, is the procedure ofchoice. A suitable cephalic vein just proximal to the wrist is identified preoperatively anda negative Allen’s test confirmed. Although up to a third of these fistulas fail to mature,the long-term patency is excellent with as many as half of them still functioning 5 to 10years after creation.

1. The whole arm, including the axilla, is prepped and draped. As no prosthetic deviceis being employed, antibiotics are not a requisite. A vertical incision is fashioned justproximal to the flexion crease of the wrist between the radial artery and the cephalicvein (black arrow). Some surgeons prefer to make an incision over the anatomic snuffbox more distally and use the deep branch of the radial artery to create the fistula (greyarrow) (Figure 2.1).

Figure 2.1

Dialysis Access Procedures 37

2. The incision is carried through the subcutaneous tissue, and then medial andlateral flaps are raised. Both the cephalic vein and radial artery are very superficiallylocated and can readily be exposed (Figure 2.2a). The cephalic vein is mobilized as farproximally and distally as possible and any large branches ligated. The radial artery isalso mobilized for a short distance. Once mobilization is complete, both the cephalic veinand radial artery are placed adjacent to each other in a side-by-side fashion. This can beaccomplished by placing a vessel loop proximally and distally, with each loop incorpo-rating the artery and vein. By tightening up on the loop, the two vessels are broughttogether (Figure 2.2b). If necessary, systemic heparin can now be administered. Controlof the vessels can be achieved by tightening up on the vessel loops or by using small vas-cular clamps (Figure 2.2c).

3. A corresponding venotomy and arteriotomy are made in the cephalic vein andradial artery (Figure 2.3a). The arteriotomy should be limited to 6 or 7 mm to prevent a

Figure 2.2

Figure 2.3


steal syndrome. A side-to-side anastomosis is then constructed using fine, nonab-sorbable monofilament suture (Figures 2.3b and 2.3c). One technique is to sew the pos-terior wall from within the lumen, then running the suture anteriorly to complete theanastomosis. Prior to reperfusion, the anastomosis can be probed through an openingcreated in the distal cephalic vein (Figure 2.3d). The probe is passed sequentially up thecephalic vein and the radial artery. The distal cephalic vein is then ligated and the arte-rial clamps released to perfuse the fistula (Figure 2.3e).

4. Alternatively, an end-to-side or end-to-end anastomoses between the radial arteryand cephalic vein can be created by dividing the vein initially (Figure 2.4a) and thenanastomosing it to the artery (Figure 2.4b).

A radiocephalic fistula usually requires 8 to 12 weeks to mature. Sometimes a second procedure is required to ligate a side branch or angioplasty an area of proximalstenosis.

Figure 2.4

b) Brachiocephalic Fistula

If a suitable cephalic vein at the wrist is not present, then a more proximal brachio-cephalic fistula may be created. In some instances, the cephalic vein might be deep inthe upper arm and not clinically visible. If it is seen on ultrasound examination and hasa diameter of 3 mm or more, then it may be suitable for fistula creation. Brachiocephalicfistulas have a primary failure rate of close to 10% and good long-term patency.


Figure 2.5

Figure 2.6

1. A preoperative evaluation is performed as described for the radiocephalic fistula.The whole arm is prepped from the wrist to the axilla. This procedure can be performedunder local anesthetic with sedation. The elbow is examined to mark the course of thecephalic vein (red arrow) and palpated to locate the position of the brachial artery(broken red line), which lies adjacent to the basilic vein (yellow arrow) (Figure 2.5).

2. Both the brachial artery and cephalic vein can be isolated through a transverse inci-sion either above (Figure 2.6a) or below (Figure 2.6b) the antecubital crease. The cephalicvein may require some mobilization to reach the brachial artery and may need to be dissected distally to the upper part of the forearm to gain adequate length for it to reach the artery. Frequently, an antecubital or median cubital vein (blue arrow) canbe found that communicates with the cephalic vein, and this vein can be used for the


Figure 2.7

Figure 2.8

anastomosis with the distal cephalic vein being ligated (Figure 2.6b). It usually easilyreaches the brachial artery (red arrow) (Figure 2.7)

3. Once an adequate length of vein is dissected free, it is divided. An end-to-side anas-tomosis is then constructed using fine, nonabsorbable monofilament suture (Figure 2.8).If the cephalic vein is found to be unsuitable, then the basilic vein can be used throughthe same approach and transposed so it runs in a more superficial course (describednext). If none of these veins is suitable, a loop forearm graft can be created through thesame incision. A primary brachiocephalic fistula matures in 8 to 12 weeks.


4. Sometimes the cephalic vein at the level of the elbow and above is of adequate size,but too deep to simply anastomose directly to the brachial artery. If the vein is deep, itmay be difficult to cannulate for subsequent dialysis. In this case the vein can be dis-sected for some length above the elbow, and then brought through a tunnel created justbelow the skin to transpose the vein to a more superficial location. This is done by firstisolating the vein either just above or below the antecubital fossa and then dissecting itfurther proximally as much as possible through the transverse incision. The vein isdivided as far distally as possible. A longitudinal counterincision is then made higher inthe arm and the same vein is isolated and mobilized into this incision (Figure 2.9). Atthis point it is helpful to gently dilate the vein (large blue arrow) with saline solution toensure that there is no twisting. The vein can be marked with a pen to maintain this ori-entation. One is now ready to create the superficial tunnel for the vein (small bluearrows).

Figure 2.9

5. A subcutaneous tunnel is created for the vein using a tunneler or other blunt instru-ment (Figure 2.10). The tunnel should start just above the brachial artery and end at theproximal extent of the upper arm incision.

6. The cephalic vein is brought through the tunnel, making sure that the vein doesnot twist as it is being pulled through. The end of the vein (blue arrow) is positionedjust above the brachial artery (yellow arrow), in preparation for the anastomosis (Figure 2.11).


Figure 2.10

Figure 2.11


Figure 2.12

Figure 2.13

7. An end-to-side anastomosis (yellow arrow) is created between the cephalic veinand the brachial artery (Figure 2.12).

8. The arterialized vein is then inspected carefully through both incisions (blue andyellow arrows) to ensure that there is no twisting of the vein and to document that thereis good flow (Figure 2.13).


c) Basilic Vein Transposition

As the basilic vein in the upper arm runs deep to the fascia, it is protected from traumarelated to venepuncture. It may be transposed to a more superficial location for dialysisaccess. This is a suitable option when the cephalic vein is inadequate for fistula creation.The primary patency for this fistula is about 60% to 70% and the long-term patency issimilar to that of a graft.

1. The procedure can be performed with a general anesthetic or local anesthetic withsedation, though the former is preferred due to the extensive dissection involved. Thewhole arm is prepped, including the axilla. The incision is begun at the antecubital creasein a vertical fashion just medial to the brachial artery pulse (Figure 2.14a). The incision is carried through the subcutaneous tissue; the fascia is incised and the brachialartery exposed. The median nerve (Figure 2.15, green arrow) lies medial to the brachialartery (yellow arrow) at this location and should be identified and preserved (Figure2.14b). Proceeding slightly more medial and still deep to the fascia, the basilic vein (bluearrow) is visualized and traced proximally, all the way to its junction with the axillaryvein (Figure 2.15). At some point, usually in the proximal third of the arm, the medial

Figure 2.14

Figure 2.15


Figure 2.16

Figure 2.17

cutaneous nerve (black arrow) is encountered. This nerve usually crosses superficial tothe basilic vein and, if injured, can result in numbness over the medial aspect of the arm.

2. Once the basilic vein is fully mobilized and all its branches ligated, it is divided asfar distal in the arm as possible and brought superficial to the medial cutaneous nerve(Figure 2.16a). If there is adequate length, the vein can be tunneled in a more lateral,subcutaneous location (Figure 2.16b). Alternatively, a lateral flap can be created subcu-taneously as a “pocket” for the vein.

3. Proximal and distal control of the brachial artery is obtained and the patient isgiven heparin. A 6- to 7-mm arteriotomy is then made and an end-to-side anasto-mosis between the basilic vein and the brachial artery is constructed using fine, nonab-sorbable monofilament suture (Figure 2.17a). Clamps are then released and flow estab-


lished in the arterialized basilic vein (Figure 2.18). The deep fascia is then closed with interrupted, absorbable sutures, keeping the basilic vein superficial to the fascia (Figures2.17b and 2.19). The basilic vein is positioned in the subcutaneous pocket, thereby relo-cating it in a more lateral and more superficial position (Figure 2.17c).

It generally takes about 12 weeks before the arterialized basilic vein is ready for can-nulation. Some surgeons prefer a two-stage procedure for basilic vein transposition. Atthe first stage, the distal vein is anastomosed to the brachial artery without mobilization.The vein is then brought to a more superficial position several weeks later. The propo-nents of this approach feel that delayed mobilization results in less damage to the vesselwall and a better chance of maturation.

d) Forearm Loop Arteriovenous Graft

Arteriovenous (AV) grafts are reserved for patients who do not have a suitable vein forprimary fistula creation. Most commonly employed grafts are made out of polytetra-fluoroethylene (PTFE). The preoperative assessment is essentially the same as forfistulas. The primary patency of PTFE grafts is in the 70% to 80% range.

Figure 2.18

Figure 2.19


1. The procedure is usually performed under a local anesthetic with sedation. Pre-operative antibiotics are utilized. A transverse incision is fashioned below the antecu-bital crease (Figure 2.20a). The antecubital, cephalic, or basilic veins may be exposed inthe subcutaneous layer (Figure 2.20b). Any one of these veins can be used for outflow. Ifthese are not suitable, the graft can be drained into the deep brachial vein.

2. If a suitable superficial vein is identified, it is gently looped and preserved. Thebicipital aponeurosis is then opened (Figure 2.21a). The brachial artery (red arrow), withits concomitant veins can be exposed deep to the aponeurosis (Figures 2.21b and 2.22).Care must be taken to avoid injury to the median nerve, which courses slightly deeperand medial to the artery.

Figure 2.20

Figure 2.21

Figure 2.22


Figure 2.23

3. A tunnel in a loop configuration is then created. A counterincision is made in themiddle of the arm, and a tunneling device is used to pass a PTFE graft, usually 6 mm indiameter, in a loop configuration (Figure 2.23).


4. Once the graft has been tunneled, the patient can be heparinized. The arterial andvenous anastomosis are performed, both in an end-to-side fashion. For the venous end,the graft can be cut at a bias to increase the diameter of the anastomosis and decreasethe chances of venous stenosis (Figure 2.24a). For the arterial end, large anastomoses are avoided to decrease the chance of developing steal syndrome (Figure 2.24b).

5. The skin is closed over the completed anastomosis (Figure 2.25). It is unnecessaryto close the deep fascia. The radial artery pulse is checked prior to completing the oper-ation. Another option for a forearm graft is to place a straight graft with inflow from theradial artery at the wrist and outflow to one of the veins in the antecubital fossa.

Figure 2.24

Figure 2.25


Figure 2.26

e) Upper Arm Arteriovenous Graft

An upper arm or brachial artery to axillary vein graft is possible in most patients,provided there is no central stenosis and no arterial disease. The early patency is excel-lent with a failure rate of only 0% to 3%. However, complications associated with the use of prosthetic material are inherent in this procedure, such as thrombosis and infection.

1. The preoperative assessment is as already described. The procedure is performedunder local or general anesthesia. The whole arm including the axilla is prepped. Thebrachial artery can be exposed above the antecubital crease through a transverse inci-sion. The axillary vein is usually exposed through a vertical or transverse incision madein the axilla (Figure 2.26a, c). The axillary incision is continued through the subcuta-neous tissue and the fascia is opened. The axillary vein can be readily exposed or, alter-natively, the brachial vein or basilic vein can be exposed more distally (Figure 2.26b).These two vessels coalesce to form the axillary vein. Any of these veins, depending ontheir caliber, may be used for outflow.

Figure 2.27


2. Using a tunneling device, a 6-mm PTFE graft is placed subcutaneously between thetwo incisions (Figure 2.27a, b). The graft should be directed lateral, as this is more comfortable for the patient during dialysis. Once the graft has been tunneled in its loca-tion, the patient may be heparinized. The venous end of the graft is cut at a bias toincrease the diameter. An end-to-side anastomosis is then performed using a fine,monofilament, nonabsorbable suture. The arterial anastomosis is then made in a similarfashion, limiting the arteriotomy to 6 or 7 mm to avoid steal syndrome. The venousclamps are first released followed by the arterial clamps and flow in the graft established(Figure 2.27c).

f) Lower Extremity Access Procedure

Use of the lower extremity for permanent dialysis access should be limited to those sit-uations in which all options involving the upper extremity have been exhausted or arenot possible. These procedures unfortunately have a high risk of failure, poor long-termpatency rates, high risk of infection, and poor tolerance by patients. Options include aprimary arteriovenous fistula utilizing the saphenous vein as the conduit and thesuperficial femoral artery as the source of inflow. Alternatively, a prosthetic graft can be used with anastomosis to the femoral artery and saphenous vein.


1. For a primary arteriovenous fistula, the saphenous vein is completely dissected outfrom its junction with the main femoral vein to a level in the mid to distal thigh (Figure2.28a). All branches are divided and the distal few centimeters of the vein is completelyfreed so that it can be brought close to the superficial femoral artery for anastomosis.The vein is ligated and divided distally. The superficial femoral artery is isolated at thislevel for an adequate length to allow for easy anastomosis. The vein is then brought tolie close to the artery. An end-to-side anastomosis is fashioned (Figure 2.28b).

Figure 2.28


Figure 2.29

Figure 2.30

2. If the saphenous vein is not of useable quality for an adequate length, then a pros-thetic graft can be used. A horizontal or vertical incision is made in the femoral region,directly over where the saphenous vein likely enters the main femoral vein. The artery,which lies just lateral to the femoral vein, is similarly dissected out. The graft is broughtthrough a tunnel, similar to as with a looped graft procedure in the forearm. The endsof the graft are anastomosed to the corresponding artery and vein (Figures 2.29 and2.30).


Peritoneal Dialysis

Peritoneal dialysis has been in wide usage since the 1960s. For some patients it is aneffective means of renal replacement therapy. Several modalities of peritoneal dialysisare now available, but the principle remains the same – fluid and solutes are exchangedvia the peritoneum.

As with hemodialysis, careful preoperative planning is required. Peritoneal dialysismay not be a viable option in patients with multiple prior abdominal surgeries asintraabdominal adhesions may preclude effective exchange of the dialysate. The patientmust be competent enough to manage the machine and catheter at home. It is a usefuloption in patients who have difficult vascular access.

Peritoneal Dialysis Catheter Placement

a) Open Technique

In 1968, Tenckhoff developed a silicone catheter that is still used for peritoneal dialysis.Several modifications of this catheter are currently available. Most of the catheters havetwo Dacron cuffs, one that is implanted just above the peritoneum and the other in asubcutaneous location. Both these cuffs create an inflammatory reaction with subse-quent fibrosis and adhesion, preventing bacterial ingrowth from the skin.

1. Typically, either a vertical or transverse incision is made in a paramedian locationbelow the umbilicus (Figure 2.31). If the patient is a renal transplant candidate, the inci-sion should be made on the left, saving the right side for the kidney.

Figure 2.31


Figure 2.32

Figure 2.33

2. The incision is carried through the subcutaneous tissue and the anterior rectussheath incised transversely (Figure 2.32a). The fibers of the rectus muscle are then splitbluntly to expose the transversalis fascia and peritoneum (Figure 2.32b). An opening ismade in the peritoneum and a purse-string suture placed around the opening (Figure2.32c).

3. The catheter is then flushed and threaded over an inserting stylet. The catheter(Figure 2.33a) can then be gently fed through the peritoneal opening into the peritonealcavity, directing it caudad (Figure 2.33b). Care must be taken to avoid injury to under-lying viscera during this maneuver. The purse-string suture is tied, securing the peri-toneum around the catheter.


4. The first cuff is seated above the peritoneum within the body of the rectus muscle.Part of the suture may be used to directly transfix the Dacron cuff. A lateral tunnel isthen created in a subcutaneous space and a small, sharp instrument passed through thetunnel into the original incision (Figure 2.33c); the free end of the catheter is graspedand pulled through. The anterior rectus sheath is then closed with nonabsorbablesutures. The second Dacron cuff is seated 1 or 2 cm away from the skin exit site to preventerosion through the skin (Figure 2.34a). It is usually not necessary to suture the catheterto the skin. In fact, this may lead to irritation and infection of the catheter site. The skinincision is closed in standard fashion (Figure 2.34b). Prior to leaving the operating room,the catheter is tested by instilling it with saline solution and then checking for drainageby placing the catheter in a dependent position.

b) Laparoscopic Technique

The advantage of the laparoscopic method is that the catheter can be placed under directvisualization, thereby reducing the risk of visceral injury and optimizing placement.Also, with this technique, the catheter may be used right away; the open techniquerequires a 1 to 2-week wait. The disadvantage is that a general anesthetic is required.

Figure 2.34


1. The whole abdomen is prepped. Usually two 5-mm trocars are adequate (Figure2.35a). Some surgeons prefer a third port as well. A 5-mm port is placed in the supraum-bilical area either using the open technique or with a closed technique using a Veressneedle. Pneumoperitoneum is established with CO2 insufflation. A second 5-mm port isthen placed in a paramedian position below the umbilicus. The peritoneal cavity is care-fully inspected for any adhesions or other abnormalities. Adhesiolysis is performed ifneeded. The Silastic peritoneal dialysis catheter is then threaded over its thin insertingstylet (Figure 2.35b). The 5-mm port in the left paramedian area is then removed andthe catheter with stylet is inserted through this opening under direct laparoscopic visu-alization (Figure 2.35c). The stylet and catheter are carefully advanced toward the supra-pubic area and the catheter threaded into the peritoneal cavity (Figure 2.35d). Thecatheter is pushed into the abdomen until the Dacron cuff is visible. This is then seated

Figure 2.35


just above the peritoneum. The stylet is then completely withdrawn leaving the catheterin place, with its tip directed into the pelvis (blue arrow) (Figure 2.36).

2. A small incision is then created laterally for the catheter exit site. Using a longgrasping instrument, a subcutaneous tunnel is created between this incision and theparamedian incision (Figure 2.37a). The end of the catheter is grasped and pulled out,situating the second cuff about 1 or 2 cm away from the skin exit site (Figure 2.37b). Thesubcutaneous tissue and skin are closed at the paramedian incision but no deeperstitches are necessary. The pneumoperitoneum is released and catheter function is testedby instilling 500 cc to 1 L of normal saline and then letting it flow out by dependentdrainage. The initial port site is then closed in standard fashion (Figure 2.37c).

Selected Readings

1. Akoh JA, Sinha S, et al. A 5-year audit of hemodialysis access. Int J Clin Pract 2005;59(7):847–851.2. Brescia MJ, et al. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula.

N Engl J Med 1966;275:1089.3. Crabtree JH, Fishman A. A laparoscopic method for optimal peritoneal dialysis access. Am Surg

2005;71(2):135–143.4. Diaz-Buxo JA. Access and continuous flow peritoneal dialysis. Perit Dial Int 2005;25(suppl 3):S102–104.5. Gray RJ, Sands JJ, eds. Dialysis Access: A Multidisciplinary Approach. Philadelphia: Lippincott Williams

& Wilkins, 2002.6. Kawecka A, Debska-Slizien A, Prajs J, et al. Remarks on surgical strategy in creating vascular access for

hemodialysis: 18 years of one center’s experience. Ann Vasc Surg 2005;19(4):590–598.7. Keuter XH, van der Sande FM, Kessels AG, de Haan MW, Hoeks AP, Tordoir JH. Excellent performance of

one-stage brachial-basilic arteriovenous fistula. Nephrol Dial Transplant 2005;20(10):2168–2171.8. Lin PH, Bush RL, Nguyen L, Guerrero MA, Chen C, Lumsden AB. Anastomotic strategies to improve

hemodialysis access patency – a review. Vasc Endovasc Surg 2005;39(2):135–142.9. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (NKF K/DOQI). Clinical prac-

tice guidelines for vascular access. Am J Kidney Dis 2001;37(suppl 1):s137–s181.10. Ramage IJ, Bailie A, Tyerman KS, McColl JH, Pollard SG, Fitzpatrick MM. Vascular access survival in chil-

dren and young adults receiving long-term hemodialysis. Am J Kidney Dis 2005;45(4):708–714.11. Striker GE, Tenckhoff H. A transcutaneous prosthesis for prolonged access to the peritoneal cavity.

Surgery 1971;69:70.12. Wilson SE, ed. Vascular Access: Principles and Practice. St Louis: Mosby, 1996.

Figure 2.36

Figure 2.37

dialysis access procedures · c) basilic vein transposition d) forearm loop arteriovenous graft e)...

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